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phenomenon13, neurotoxicity, major vascular occlusion, chronic pulmonary toxicity, and secondary
malignancies. Pulmonary toxicity is a major concern in the aviation world because chronic exposure to
100 per cent oxygen, which can occur occupationally, may worsen this condition.
Aeromedical considerations
Fortunately, recurrent low-grade superficial urothelial carcinoma is unlikely to result in sudden
incapacitation. However, recurrence may also present as metastatic disease, which can result in
significant and potentially sudden impairment. Brain metastases of urological malignancy can result in
significant unrecognized cognitive impairment. Ongoing treatment also poses risks to flight safety. For
these reasons, the recommendation for a pilot to return to flying duties should occur only after the
individual has been disease-free for two years.
Aeromedically, impairment from renal cell carcinoma may result more from complications of surgery
than from any other cause. Lower-staged tumours have a favourable survival rate and, therefore, radical
nephrectomy is usually recommended for these patients. The remaining kidney needs increased vigilance
to ensure its function but if it is functioning well, the pilot may return to flying duties after two years
provided he is disease free and off all medications.
13 Raynaud’s phenomenon: intermittent bilateral ischaemia of fingers, toes, and sometimes ears and nose, with
severe pallor and pain. After Maurice Raynaud, French physician (1834-1881)
ICAO Preliminary Unedited Version — November 2009 III-6-19
A pilot with carcinoma of the prostate should not participate in flying duties until definitive therapy has
been completed and no evidence of recurrence or metastasis has occurred for a period of at least two
years. Testicular cancer has the same restrictions for aviation duties. Long-term morbidity potential of
chemotherapy, especially with bleomycin, and the logistics associated with the surveillance of
lower-stage patients make returning to flying sooner unreasonable.
CONCLUSION AND SPECIAL CONSIDERATIONS
As noted in the introductory statements of this chapter, it is understood that a degree of interpretation and
assessment must be exercised by the medical examiner, often in consultation with specialists and the
medical assessor of the Licensing Authority. Many such cases may have to be referred to the medical
assessor for final aeromedical disposition. Many urological conditions have been discussed that are
incompatible with flight, including infections, stone disease, malignancy, and some urological
medications. One such medication not previously discussed is sildenafil (Viagra®), a selective 5-
phosphodiesterase inhibitor that enhances the vasodilatory effects of nitric oxide on corporeal arterial
sinusoidal smooth muscle. This medication is commonly used in the medical treatment of erectile
dysfunction and is not to be used for 24 hours prior to anticipated flight. Furthermore, one must abstain
from its use when concomitant nitrates are being used, as deaths have been reported with this
combination.
Testosterone replacement should not preclude a pilot from flying and is typically well tolerated with
minimal side effects when taken for hypogonadal states. Of course, the individual must undergo a full
work-up to rule out the pituitary gland as the cause. Appropriate evaluation for pituitary conditions
includes ensuring normal follicular stimulating, luteinizing, and prolactin levels. An MRI of the pituitary
gland and sella turcica is required for patients with any abnormalities of these hormones.
Adrenal pathology is discussed elsewhere in this Manual but the surgical care of many adrenal lesions is
often performed by a urologist. Suffice it to say that lesions, such as adrenal adenoma,
phaeochromocytoma, neuroblastoma, and carcinoma will likely preclude medical certification. Complete
eradication of these tumours with subsequent normal physiologic states or, in the case of malignancy, a
two-year disease-free period is required prior to resumption of aviation duties.
In this chapter, the most common urological conditions the aviation medical examiner may encounter
have been reviewed. For urological diseases not included here, appropriate consultation with medical
specialists and the medical assessor of the licensing authorities is key in providing appropriate
aeromedical dispositions and ensuring flight safety.
REFERENCES/SUGGESTED READING
This manuscript has been extracted from information within three primary sources.
1) Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell’s Urology.
8th Edition. Saunders. Philadelphia. 2002.
2) USAF On-Line Aeromedical Consult Service Waiver Guide:
http://wwwsam.brooks.af.mil/web/consult_service/waiver%20guide/html/genito.htm
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Manual of Civil Aviation Medicine 2(6)
